Problem Identified: Ineffective airway clearance Nursing Diagnoses: Ineffective Airway Clearance r/t bronchospasm, increased secretion production

and decreased energy. Cause Analysis: In COPD, smoke or other environmental pollutants irritate the airways, resulting in hypersecretion of mucus and inflammation. This constant irritation causes the mucus-secreting glands and goblet cells to increase in number, ciliary function is reduced, and more mucus is produced. The bronchial walls become thickened, the bronchial lumen is narrowed, and mucus may plug the airway. Fatigue, exhaustion, malaise eventually occurs and the patients ability to expectorate secretions is affected. (Brunner and Suddarth. MedicalSurgical Nursing, 10 ed, p 569-570).
Cues Subjective: sakit akong dughan inig mu ubo ug muginhawa kug lalum. As verbalized by the patient P- when coughing and deep inhalation. Q- sharp pain R- RLQ of abdomen (with penrose drain) S- 3-4/10 T- brief flash pain. Objective: Presence of fine crackles over lung bases . Respiratory Rate 31bpm. Productive cough with white Assisted client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms LTO: Within 3 days of nursing interventions the patient will be free from adventitious sounds and will not manifest any signs or symptoms of respiratoy distress. STO: Within 8 hours of nursing interventions the patient will be able to maintain patent airway, discomfort upon coughing and deep inhalation will be relieved, and will demonstrate behaviors to improve airway clearance. Objectives Independent: Auscultated breath sounds. Noted adventitious breath sounds such as wheezes, crackles, or rhonchi. Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds, such as scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds Assessed and monitored respiratory rate. (severe asthma). Tachypnea is usually present to some degree and may be pronounced on admission, during stress, or during concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration. LTO: After 3 days of nursing interventions, the patients crackles is still present but no signs of respiratory distress were noted. Nursing Interventions Rationale STO: After 8 hours of nursing interventions, the patient was able to maintain patent airway, pain scale is reduced to 1/10, participated in activities in improving his ability to expectorate lung secretions. Evaluation
th

sputum. with O2 inhalation @2 L/min via nasal cannula (+) Dressing on abdomen, penrose drain and colostomy bag on LLQ. Chest PA View: (+) Minimal pleural thickening, left lower chest.

bed.

and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

Provides client with some means to cope with Encouraged and assist with abdominal or pursedlip breathing exercises (use of spirometry). Cough can be persistent but ineffective, Observed for persistent, hacking, or moist cough. Assisted with measures to improve effectiveness of cough effort. especially if client is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion. and control dyspnea and reduce air-trapping.

Collaborative: Administered medications as indicated: Pulmodual 5-6 drops Q6H RTC Inhaled anticholinergic agents are now considered the first-line drugs for clients with stable COPD because studies indicate they have a longer duration of action with less toxicity potential, whereas still providing the effective relief of the beta-agonists. Used to correct and prevent worsening of Administered 02 inhalation @ 2L/min via nasal cannula. hypoxemia, improve survival, and quality of life. Supplemental oxygen can be provided during exacerbations only, or as a long-term therapy.

Reference: Doenges, M.E. (2008). Nursing Care Plan, 8th ed. p. 124-125